Evidence-based assessment. Here are your objectives for the week. Assessment is the first step in the nursing process to planning client and family-centered nursing care.
As nurses, we assess the client, recognize cues, cluster information, to give us our nursing diagnosis. There are different types of data that we collect during our assessment. Subjective data is that data that the client or the caregiver shares with us.
Objective data is what the nurse observes by inspection, percussion, palpation, and auscultation when doing a physical examination or head-to-toe assessment. on a client. There are different types of databases that the nurse uses depending on the clinical setting and the client situation.
A complete database is often collected either in the provider's office or the clinic when we don't have any information on your client. This includes a complete health history, past and current health problems, and a head-to-toe physical assessment. The focused or problem-centered assessment or databases, this is for a limited or an acute problem the client is presenting with. So a fever and a sore throat is an example that I would use. A follow-up database, this is used in all settings to assess if whatever identified problem has gotten better, chronic conditions are not getting worse, and are there any recent changes in health status.
An emergency database is a very rapid collection of data in an emergency that is life-threatening. So an example would be an allergic reaction or drug overdose. Once the client is stable, then a more thorough database can be collected.
Nurses use clinical judgment and diagnostic reasoning to make nursing diagnoses after gathering assessment information. Critical thinking principles help nurses to analyze the data collected and make the best evidence-based decisions that impact care at the bedside. So let's look at critical thinking principles.
It proceeds through sequential steps from novice to expert as you gain more experience. We utilize a multi-dimensional thinking approach to interpret data. We validate and confirm findings based on non-judgmental interpretation of the data collected. We cluster data information to support evidence as well as to rule out inconsistent clinical findings in terms of a differential diagnosis.
Priority problem level. First level priority is emergent, life-threatening, and immediate. Second level priority is next in urgency, requiring attention to avoid further deterioration. Third level priority is important to the client's health but can be addressed after more urgent problems are addressed. Collaborative problems, this is an approach to treatment and involves multi-disciplines like therapies, nutrition and dietary, those sorts of things.
So let's talk about clinical decision making. Randomized clinical trials are a current and best clinical practice based on research standards focused on systematic reviews. Evidence-based practice has been around since the 1970s.
These RCTs are ongoing in many clinical settings and you may see them as you experience clinical practice this semester. These provide the standard of care that improves client outcomes. We utilize evidence-based practice in conjunction with provider experience that leads to better outcomes for clients in specific situations. Evidence-based practice is the gold standard. This culture is evident in both the undergraduate and the graduate levels in nursing.
High-level assessment skills. Assessment skills require hands-on expertise refined to a high level. The nurse is the first and often the only health care professional to see an individual in many communities.
The nurse is the only health professional continually present at the bedside in hospitals. You are the provider's eyes and ears. Life cycle, wholism, and culture must not detract from the importance of assessment skills themselves.
The more clients you access, the more you will become expertise at assessing clients in clinical settings. Assessment through the life cycle. Growth and development, age-specific milestones, immunizations are some of the health promotion and disease prevention assessments done at a well visit.
You will learn more in PEDS and OB classes in Level 3. There are age-specific charts for periodic health examinations as a positive approach to health assessment. So to define lifetime schedule of health care, there are charts that have a list with a frequency schedule for periodic health visits and preventative services for specific age groups in your textbook. Age-specific Most charts focus on major risk factors specific for each age group based on lifestyle, health needs, and problems.
So we want to incorporate health promotion disease prevention at every health visit, not just at the one annual physical examination. Health education and counseling are highlighted as a means to promote health at every visit. Frequency of assessments. While the interval of assessment varies with illness and wellness needs, ill people seek care because of pain or abnormal signs and symptoms. Hospitalized clients require frequently repeated head-to-toe focused and focused reassessment in response to treatments.
This prompts an assessment. Gathering a complete episodic follow-up or an emergency In a hospitalized client, when would you do each of the assessments listed? Routine periodic examinations might include the following services for preventative health care. A screening history for dietary intake, physical activity, tobacco, alcohol, drug use, and sexual practices.
Counseling for injury prevention, substance use, sexual behavior, diet and exercise, and dental health. Immunizations. Prophylaxis with a multivitamin with folic acid for females capable of or planning a pregnancy.
What is a routine periodic assessment or a well visit? How often should they occur in certain client bases? Well persons, well annual or yearly, opinions are changing about assessment intervals. Annual checkups are kind of vague.
What does it constitute? Is it necessary? Does it give sometimes an implicit promise of health and thus provide false security to the client? The timing of formally accepted procedures is now variable.
For example, annual pap tests. They've had a lot of normal ones. They may not be seen as often.
or they may space them out a little bit. The same annual routine physical examination cannot be recommended for all persons because health priorities vary among individuals, age groups, and risk categories. So how do you assess risk and determine how often a client needs to be seen by a provider? Questions?
Please reach out to your course professor.